Ensuring that transgender patients receive respectful, appropriate, and legally compliant care is an essential responsibility for primary care providers. The way medical records are managed plays a crucial role in safeguarding patient confidentiality while also ensuring that individuals receive the correct healthcare interventions. This guidance aims to help general practitioners (GPs) and practice staff record transgender status in medical notes in accordance with the Gender Recognition Act 2004 (GRA), NHS Digital policies, and best clinical practice.
The Gender Recognition Act 2004 provides a legal framework for individuals who have transitioned and obtained a Gender Recognition Certificate (GRC). Once a person has been granted a GRC, they are legally recognised in their affirmed gender for all purposes. This means that primary care records must be updated to reflect their acquired gender, and any previous gender identity must not be disclosed without their explicit consent.
It is a criminal offence under the GRA to disclose a person’s transgender history if they have a GRC, unless they have given explicit permission to do so or disclosure is required by law. This protection extends to all individuals working in primary care, including GPs, administrative staff, and other healthcare professionals. Breaching this confidentiality can result in legal consequences.
However, it is important to note that a person does not need a GRC to be recognised in their affirmed gender within primary care. Patients have the right to request changes to their name and gender marker in their medical records at any time, regardless of whether they have undergone any medical or legal transition processes. While the NHS administrative systems currently require individuals to be registered as either male or female, practice staff should ensure that a patient’s preferred name and gender identity are recorded and respected in all interactions.
When a patient informs their GP practice that they wish to be recognised in a gender different from the one assigned at birth, the practice should support them in making the necessary updates to their records. This process typically involves updating demographic details, including their name and gender marker. It is essential that these changes are made sensitively, ensuring that the patient’s wishes are central to the approach taken.
The NHS does not currently allow for non-binary or gender-diverse identities to be formally registered in primary care systems, as all patients must be recorded as either male or female. Despite this limitation, practices should make efforts to respect a patient’s identity in all correspondence, interactions, and informal documentation.
If a patient has obtained a GRC, the NHS Business Services Authority may issue a new NHS number to reflect the change in gender. In such cases, a new medical record may be created, with limited access to the previous records. However, if the patient has not obtained a GRC, their NHS number will remain the same, and their records will be updated within the existing file.
Ensuring transgender patients receive the appropriate medical care requires attention to the individual’s specific healthcare needs. This is particularly relevant when it comes to routine screenings, as automatic screening invitations are typically based on the sex recorded in a patient’s NHS record rather than their clinical requirements.
For transgender men who were assigned female at birth, it is essential to ensure that they continue to receive necessary screenings such as cervical smears and breast cancer screening, where appropriate. If a transgender man has not undergone a hysterectomy, they remain at risk of cervical cancer and should be invited for routine screening, even if their NHS records list them as male. Since the automated NHS screening system may not generate invitations for male-registered patients, practice staff should manually ensure that these individuals are offered the appropriate tests.
Similarly, transgender women who were assigned male at birth and who have undergone hormone therapy may develop breast tissue, increasing their risk of breast cancer. If a transgender woman is taking oestrogen, she should be considered for breast screening in line with national guidelines. However, since the NHS system may not automatically invite a transgender woman registered as male for these screenings, it is important that clinicians manually review and arrange appropriate screening interventions.
Prostate cancer screening should also be considered for transgender women, as they retain a prostate gland even after gender-affirming surgery. While the risk may be lower due to the effects of hormone therapy, it is still advisable to ensure that prostate health is monitored where necessary.
Many transgender patients receive hormone therapy as part of their transition, often initiated and managed by a Gender Identity Clinic (GIC). However, GPs are frequently asked to continue prescribing and monitoring hormone therapy under a shared care agreement.
Before prescribing hormone treatments, it is important that GPs have a clear understanding of the medications involved and their potential effects. For example, oestrogen therapy in transgender women can increase the risk of venous thromboembolism, while testosterone therapy in transgender men can lead to polycythaemia. Routine blood tests should be conducted to monitor hormone levels and assess for any adverse effects.
GPs who are not comfortable managing hormone therapy under a shared care agreement should ensure that transgender patients continue to have access to specialist services. It is crucial that practices do not withhold care due to a lack of expertise but instead seek guidance from gender specialists or refer the patient to an appropriate service.
Maintaining confidentiality is particularly important when dealing with transgender patients. If a patient has transitioned and wishes to keep their previous gender history private, practice staff must ensure that no unnecessary information is disclosed in correspondence or medical interactions. This includes ensuring that deadnames (a transgender person’s previous name) are not used in letters, appointment bookings, or interactions with third-party services.
For patients who have legally transitioned and obtained a GRC, their previous gender identity should not be recorded in easily accessible notes or routinely referenced in consultations. If it is necessary to document aspects of a person’s medical history that relate to their assigned sex at birth, such as reproductive health considerations, this should be done in a way that respects the patient’s dignity and privacy.
It is also important to ensure that staff members, including reception and administrative personnel, are trained in handling transgender patient records appropriately. Simple mistakes, such as calling a patient by the wrong name or sending correspondence addressed incorrectly, can cause significant distress and undermine trust in the healthcare system.
Providing high-quality care to transgender patients requires an understanding of both the medical aspects of transition and the social and psychological challenges that transgender individuals may face. Ensuring that all practice staff, from GPs to receptionists, receive training on transgender healthcare can significantly improve the experience of patients seeking care.
Training should include guidance on appropriate terminology, the importance of using correct pronouns, legal rights under the GRA, and the clinical considerations involved in transgender healthcare. A respectful and inclusive approach not only benefits transgender patients but also helps create a healthcare environment that is welcoming and supportive for all individuals.
Recording transgender status in primary care requires a careful balance between legal compliance, clinical accuracy, and patient respect. Practices should ensure that transgender patients receive the correct care while also maintaining strict confidentiality and adhering to legal protections under the Gender Recognition Act 2004.
By taking proactive steps to ensure that transgender patients are treated with dignity and that their healthcare needs are met, GP practices can play a crucial role in promoting inclusivity and ensuring equitable access to high-quality medical care.